Volume 2 Chapter 1

  1. Chief Complaint
    The reason the ambulance was called
  2. Differential Field Diagnosis
    The list of possible causes for your patient's symptoms
  3. Open-Ended Questions
    Questions that allow your patient to answer in detail
  4. Closed-Ended Questions
    Questions that elicit a one or two word response
  5. Active Listening
    The process of responding to your patient's statements with words or gestures that show your understanding
  6. Active Listening Skills
    • Facilitation- saying "mm hmm" or "go on" as the patient is talking to you
    • Reflection- repeat the patients words in a question
    • Clarification- asking questions about the patients statements to get more information
    • Empathy- saying things like "that must be very hard for you"
    • Confrontation- letting the patient know that you think there is more going on
    • Interpretation- "are you afraid you are having a heart attack but don't want to admit it?"
  7. Comprehensive Patient History
    • Preliminary Data
    • Chief Complaint
    • Present Injury/Illness
    • Past History
    • Current Health Status
    • Review of Systems
  8. Preliminary Data
    • -Date and Time of exam
    • -Age
    • -Sex
    • -Race
    • -Birthplace
    • -Occupation
  9. Chief Complaint
    Determine the CC and Primary Problem
  10. Primary Problem
    The underlying cause of the patients symptoms
  11. Present Illness

    • Onset of problem
    • Provocative/Palliative factors
    • Quality
    • Region/Radiation
    • Severity
    • Time
    • Associated Symptoms
    • Pertinent Negatives
  12. Tenderness
    Pain that is elicited through palpation
  13. Referred Pain
    Pain that is felt at a location away from its source
  14. Past History
    • General state of health
    • Childhood diseases
    • Adult diseases
    • Psychiatric illness
    • Accidents or injuries
    • Surgeries or hospitalizations
  15. Current Health Status
    • Current medications
    • Allergies
    • Tobacco
    • Alcohol, drugs and substances
    • Diet
    • Screening tests
    • Immunizations
    • Sleep patterns
    • Exercise/leisure
    • Environmental hazards
    • Use of safety measures
    • Family history
    • Home situation and significant others
    • Daily life
    • Important experiences
    • Religious beliefs
    • Patient's outlook
  16. CAGE Questionairre
    • Cut down on your drinking?
    • Annoyed by criticism of your drinking?
    • Guilty feelings about drinking?
    • Eye-opener in the morning?
  17. Review of Systems
    List of questions categorized by body system

    • General- weight gain, fatigue
    • Skin- lumps, sores, dryness
    • Head, eyes, ears, nose and throat (HEENT)
    • Respiratory- wheezing, coughing, pneumonia
    • Cardiac- chest pain, palpitations, SOB
    • Gastrointestinal- bowel movements, vomitting
    • Urinary- pain, blood, color, excessive
    • Male genitalia- sores, masses
    • Female genitalia- periods, bleeding, pain, pregnancies
    • Peripheral vascular- pain
    • Musculoskeletal- pain
    • Neurological- weakness, numbness
    • Hematologic- anemia, blood transfusions
    • Endocrine- thyroid, sweating
    • Psychiatric- nervous, stress
  18. Tinnitus
    Sensation of ringing in the ears
  19. Hemoptysis
    Coughing up blood
  20. Dyspnea
    Difficulty breathing
  21. Orthopnea
    Difficulty breathing while supine
  22. Paroxysmal Nocturnal Dyspnea
    Sudden onset of SOB at night
  23. Hematemesis
    Vomitting blood
  24. Polyuria
    Excessive urination
  25. Nocturia
    Excessive urination at night
  26. Hematuria
    Blood in urine
  27. Dysmenorrhea
    Difficult or painful menstruation
  28. Intermittent Claudication
    Intermittent calf pain while walking that subsides with rest
  29. Special Challenges
    • Silence
    • Overly Talkative
    • Multiple Symptoms
    • Anxious
    • Needing Reassurance
    • Anger/Hostility
    • Intoxication
    • Crying
    • Depression
    • Sexually Attractive Patients
    • Confusing Behaviors/Histories
    • Limited Intelligence
    • Language Barriers
    • Hearing Problems
    • Blindness
    • Talking with Family or Friends
  30. Depression
    A mood disorder characterized by hopelessness and malaise
  31. Dementia
    A deterioration of mental status that is usually associated with structural neurologic disease
  32. Delirium
    An acute alteration in mental functioning that is often reversible
Card Set
Volume 2 Chapter 1
Volume 2 Chapter 1